Defining Behavioral Interventions Michael Sweat Ph D The

Defining Behavioral Interventions Michael Sweat, Ph. D The Johns Hopkins University Bloomberg School of Public Health Department of International Health Thanks to Kevin O’Reilly & WHO, Population Council / Horizons, NIMH

Key Take Away Messages o o The current language in use regarding interventions is muddled Intervention programs are comprised of multiple intervention components We need clear standards for intervention components We need to consider the blend of intervention components to maximize program success

Background o Our work shows that most intervention programs are almost always made up of multiple intervention components n o o o Yet they are identified only by the most prominent component; We often have different understandings of what specific interventions are; As a result, intervention evaluation is difficult; A deeper understanding of interventions should include examining the synergy of multiple intervention components;

Theoretical Assumptions o To a large degree, how intervention programs are constructed is a reflection of theory they are based on (either overtly or implicitly) n There a variety of theoretical trajectories to consider o o Individual-level Community & Social Multi-level and ecological Dynamic / iterative theories

Getting beyond the individual

Bronfenbrenner’s Ecological Model

Psychological Factors: Knowledge Attitudes Beliefs Perceptions Risk Perception Environment: -Access to Condoms -Behavior of Partner -HIV Prevalence of Sex Partners Intervention Program Characteristics: Quality, Intensity, Coverage, Costs Behaviors: Condom Use Number of Sex Partners Frequency of Sex Health Outcomes: HIV Incidence

Considering causal pathways: at what point do we focus?

Proximal / Distal Causal Effects Organize meetings, train on advocacy, provide legal rights, provide venue… Social Mobilization Increased empowerment by women and increased access to financial resources Increased Condom Use Reduced HIV Incidence

How quickly can we expect interventions to take effect? Cleland Paper o o Examined the uptake of condoms between 1993 -2001 in 18 countries Among young women, median increase of 1. 4% per year in condom use for pregnancy prevention by single women n o Cumulative increases in condom use from 19. 3% to 28. 4% Year to year effects appear small n But cumulative effects are substantial

How have we been defining HIV interventions? o Activity n o Counseling, Testing, Education, Training, Policy enactment, Condom Distribution Mode of delivery n Mass Media Peer Education Faith-based Community-based n MSM, IDU, CSW, Work Place, School-Based Interventions n n n o o Target Population & Setting Commodity n n n o Outcome or Goal n n o Condom Social Marketing Needle Exchange Micro-credit Abstinence Empowerment Theory n n Structural Intervention Policy Intervention

These strategies for defining interventions are often unsatisfactory o o Reduces the intervention to uni-dimensional aspects They are not very descriptive n n o Makes it difficult to evaluate and compare across programs Defining interventions by risk groups Can be pejorative and harmful o o o Reduces people to a behavior Can stigmatize “General Population” intervention n o Interventions contain elements of all of these categories n n n o Code for “Normal People” Activity Delivery Mode Target Population & Setting Commodity (often) Outcome Theory Becomes even more complex when an “intervention” is a program that include various intervention components

Data from the Synthesizing Intervention Effectiveness Study

Methods 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Define the topic Develop inclusion criteria Create a list of search terms Systematically search the literature Screen search results Acquire articles Screen full-text articles and select studies for inclusion Extract study data into standardized format (code) Resolve coding discrepancies Assess study rigor

Psychosocial Support for HIV-Infected Persons: Flow Chart from Synthesis Search Potentially relevant abstracts identified during initial computer based search, hand search & secondary search (N=69) Abstracts excluded during screening process for not meeting search criteria (N=38) Articles retrieved for more detailed evaluation (N=31) Articles identified as background material (N=30) Articles excluded for not meeting inclusion criteria or background criteria (N=0) Articles meeting eligibility for inclusion in the systematic review (N=1)

Intervention topics o Completed reviews: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Voluntary counseling and testing (VCT) Condom social marketing Partner notification Family planning for HIV infected women Mass media Abstinence and abstinence only Peer education Needle syringe exchange Psychosocial support Treatment

Intervention topics o Reviews in progress or upcoming: 11. 12. 13. 14. 15. 16. 17. 18. Comprehensive sex education Free condom distribution Behavioral counseling Income generation Diffusion interventions Built environment interventions Interpersonal skills training Policy interventions

Overlap in intervention components FP+ VCT CSM MM PE NE 1 Condom Comp sex Educ dist 2 5 MM 1 Abs 1 PE 5 1 3 1

5 Intervention Areas o o o Condom Social Marketing Peer Education Micro-Finance Social Mobilization Structural Interventions to Reduce Gender-Based Violence

The way forward… o Define interventions more holistically n o o o Consider Activity, Delivery Mode, Target Population & Setting, Commodity, Outcome, Theory Recognize that intervention programs include multiple components Establish guidelines for key components Communicate the multi-component nature of intervention programs

Creating Standards o Create standards based on empiric research n n n o Generate consensus on standards Publish these standards Refer to the standard model with short-hand Has been done effectively with HIV Voluntary Counseling and Testing n A set of principles developed Consensus efforts taken Guidelines published Guidelines updated as the epidemic has changed n Standard treatment approaches n n n o Many analogs in medicine o o o Often complex Guidelines Available – Good Clinical Practice Standards Example: Angioplasty

Pros of Standardization Pros: o n n o Allows for standard delivery which can avoid unintended and unethical consequences; Assists in training and quality control; Facilitates a common understanding of what the intervention is; Enhances ability to evaluate and replicate; Works best for intervention components that have clear causes and effects

Cons of Standardization o Cons: n n Dissuades from tailoring intervention approach to complex needs and populations; Complex intervention components are more difficult to standardization

Value of Bundling Interventions Examples of ethical mandates to provide packages of interventions; o Testing and treatment; n o n Diagnosis of infectious status and partner notification / risk reduction facilitation (access to condoms); Enhancing efficacy with bundling interventions: o n n o o n o In lieu of treatment preventative benefit of testing may mitigate this mandate; Meeting multiple needs; Enhancing efficiency; Referral strategies; Challenges of clustering interventions: Training and standardization of component parts; Cost and complexity

5 Intervention Areas o o o Condom Social Marketing Peer Education Micro-Finance Social Mobilization Structural Interventions to Reduce Gender-Based Violence

Components of a Potential Intervention o Women are provided micro-finance to procure a small stall where they can sell condoms to their peers. n o The condoms are branded and promoted by a national CSM program. The women are trained in risk reduction education, and they are supported to meet regularly to share ideas, support and protect one another, and make recommendations on the overall project.

This program includes all of these components, each of which can have standards of excellence o o o Condom Social Marketing Social Mobilization Peer Education Micro-Finance Structural Interventions to Reduce Gender-Based Violence

Group Work o Review the definition provided and reflect on the following: n n n Core Activities Delivery Mode Target Population & Setting Commodity (if appropriate) Outcome Theory

What do we mean by a “structural intervention” o o Structural – a written policy or law Environmental – interventions that strive to change the physical or social environment to affect behavior change We recognize that there are other definitions….